Substandard and counterfeit drugs represent a global public health crisis.
However, there is little economic analysis of the market given the paucity of data. Focusing on 8 drug types on
the WHO-approved medicine list, we constructed an original dataset of 899 drug samples from 17 low- and
median-income countries and tested them for visual appearance, disintegration, and analyzed their
ingredients by chromatography and spectrometry. Fifteen percent of the samples fail at least one test and can
be considered substandard. After controlling for local factors, we find that failing drugs are priced
13-18% lower than non-failing drugs but the signaling effect of price is far from complete, especially for
non-innovator brands. The look of the pharmacy, as assessed by our covert shoppers, is weakly correlated
with the results of quality tests. These findings suggest that consumers are likely to suspect low quality
from market price, non-innovator brand and the look of the pharmacy, but none of these signals can perfectly
identify substandard and counterfeit drugs. Indeed, many cheaper non-innovator products pass all quality
tests, and are genuine generic drugs. This suggests that policies in favor of these more affordable
generic drugs may potentially weaken the signaling effect of price and increase the opportunity for
counterfeit entry into the market. One way to counter this effect is directly providing better information about
drug quality.